Electrocardiogram monitoring apparatus

ABSTRACT

A monitoring apparatus is disclosed for automatically analyzing electrocardiograms in order to detect myocardial infarction. The apparatus for observing heart rhythm disturbances comprises a logic system which establishes a sequence of timed windows occurring during scanned heartbeat intervals. The logic system further electrically records and stores the windows in which electrocardiogram threshold levels occur over several regular heartbeat intervals to provide a normal, reference pattern. After which, the logic system electronically determines the window or windows in which the threshold levels occur in subsequent heartbeat cycles. A compare logic system is then provided to compare the determined window or windows with the normal, reference pattern. Finally, an alarm system is provided that is responsive to any variations or non-identities of the compared patterns.

32am? A 1 X 3983997661 United State c /w [111 3329,7615 Herz 51. 'Aug. 13, 1974 j [54] ELECTROCARDIOGRAM MONITORING Primary Examiner-Alfred E. Smith PARATUS Attorney, Agent, or Firm-Robert M. Vargo; Alan C.

[75] Inventor: Rudolf Herz, Denzlingen, Germany Rose; Alfred Levme [73] Assignee: Fritz Hellige, & Co., G.m.b.H., [57] ABSTRACT Brelsgau Germany A monitoring apparatus is disclosed for automatically [22] Filed: Apr. 2, 1973 analyzing electrocardiograms in order to detect myocardial infarction. The apparatus for observing heart rhythm disturbances comprises a logic system which establishes a sequence of timed windows occurring [21] Appl. No.: 346,913

[30] Foreign Application Priority Data during scanned heartbeat intervals. The logic system further electrically records and stores the windows in l 2217 Apr 972 Germany 235 which electrocardiogram threshold levels occur over 52 us. Cl. 324/77 R, 128/206 A Several regular heartbeat intervals to Provide a 51 Int. Cl ..G01r 23/16 mill reference pattern- After which, the logic System [58] Field of Search" 324/77 R; 128/206 R 206 A electronically determines the window or windows in which the threshold levels occur in subsequent heart- [56] References Cited beat cycles. A compare logic system is then provided to compare the determined window or windows with UNITED STATES PATENTS the normal, reference pattern. Finally, an alarm sys- 3,267,933 8/1966 MlllS et a1. 128/206 A tem is provided that is responsive to any variations or 3,658,055 4/1972 Abe et al. 128/206 A nomidemities of the Com ared atterns 3,698,386 10/1972 Fried 128/206 A p p 9 Claims, 6 Drawing Figures -5mm i Z! APfZ/A/l- {j AMPLIFIER fl/pfff'flK 7- Lg F" 27m. #14214 i ZI MA/A/ Ali/9M SUPTZESSOR 44/ ffllfifif Vff/M/M/ff l a/a/mz we i m" 24 N Army a" l 7541/1" 01/5? wrap/14m AUTOMATIC 01/55? 106/5 70 646! \Q AMPLIFIER 2 r 4M)? uk, 1 from Q @l .70

' v VOLTAGE Z X 7 DIVIDER 227 E 2 I flflzfifl7/0X/-fl[V/[[ 7 l 55! J'ff/M/l/ Amt/W5 Amp/M fff-Jfll/fl Z m Mg ?[L'DGV/f/fll/ Z5 /Q; D67: ppEV/fll/fl y 4670/?! 9 W T u Ame/u W zz/rr. j// p 211/ r sew/ea j or: m 324/7??? PATENTEDAUQ 13 I974- WISH-'5 ELECTROCARDIOGRAM MONITORING APPARATUS BACKGROUND OF THE INVENTION such as ventricular tachycardia, flutter or fibrillations are almostalways preceded by abnormal variations in the electrocardiogram (hereinafter referred to as ecg). A recognition of these variations, therefore, is important to prevent such dangerous arrhythmias by remedial treatment.

The variations that announce the onset of serious arrhythmias mentioned above, are particular QRS- portions or ventrical portions that appear earlier than the normal heartbeats and differ in shape from the basic cardiac cycle. These stimulations are named after their regional source in the atrium or ventricle of the heart as supraventricular or ventricular extrasystoles (hereinafter referred to as SES or VES, respectively).

The probability of an onset of dangerous arrhythmias of the heart differs with the type and number of extrasystoles and also differs with the time distance from the prior stimulation. Normally, the probability of occurence of ventricular tachycardia, flutter or fibrillation is smaller if only supraventricular extrasystoles (SES) appear. It is much larger if ventricular extrasystoles (VES) appear. Moreover, immediate danger exists when the extrasystole appears in the final phase of the stimulation or if the source of stimulation of the ventricular extrasystole is changing in the myocardium. These last described extrasystoles are named polytope, multifocale or polymorph VES. They usually indicate the onset of fibrillation.

Ventricular extrasystoles differ in their shape from the normal QRS-portion and from supraventricular extrasystoles. Additionally, the shapes of the polytope VES differ from each other. Heretofore, electronic appliances have been provided that automatically count appearing extrasystoles and release an alarm system when a certain frequency is registered. The disadvantage of these appliances is that they also count the less dangerous supraventricular extrasystoles and, as a result, release their alarm system more often than necessary.

Other appliances are known that count extrasystoles that appear only after a certain time limit from the QRS-portion. In these appliances the time limits are manually adjustable at the beginning of the observations to comply with the -1 distances of the electrocardiograms. In this manner, the dangerous extrasystoles which appear in the T-wave portion, can be counted separately. The shortcoming with this type of apparatus is the adjustment of the time limit is related only to the QT-portion of the heart frequency during the time of adjustment. In case of a change of heartbeat frequency and short variations of the distances of the RR-interval, extrasystoles can be classified faultily as dangerous or,

on the other hand, dangerous extrasystoles will not be counted.

Further appliances are known which differentiate ventricular extrasystoles from supraventricular extrasystoles and normal QRS-portions.

One of these appliances can measure the distance of each QRS-portion and investigate whether this distance differs more than 15 msec. from a registered ORA- portion taken at the beginning of the control. A QRS- portion larger than 15 msec is counted as a ventricular extrasystole. (Such an apparatus is described in US, Pat. No. 3,524,4422.)

Another appliance of the type discussed above measures the area of each QRS-portion above the zero line and investigates whether this area differs by a limited value from the one given at the beginning of the observation. Those QRS-portions which are adequately enlarged are counted as ventricular extrasystoles.

These known appliances that distinguish ventricular extrasystoles from supraventricular extrasystoles and normal QRS-portions have a shortcoming in that the electronic means for examining the VES are insufficient in that the shape of the QRS-portion is determined by this equipment only in a rough manner. Therefore, those types of VES are not counted which only slightly differ in their shape from SES or normal heartbeats.

SUMMARY OF THE INVENTION The present invention obviates the above-mentioned shortcomings by providing monitoring apparatus that is capable of automatically recognizing variations in electrocardiograms and thereby guaranteeing an accurate observation of heartrhythm disturbances.

In its broadest aspect, the invention comprises logic means for recognizing wave shapes by determining and comparing the time position of threshold values of these waves. More particularly, the observed portions of the electrocardiogram digitalized, whereby a scanned section of the heartbeat interval actuates a number of flip-flops in work position and produces thereby a characteristic bit pattern which is compared with a previously stored bit pattern. In this manner, even minor pathological shape variations of the potential waves are automatically analyzed and signalized.

The features of the present invention which are believed to be novel are set forth with particularity in the appended Claims. The present invention, both as to its organization and manner of operation, together with the further advantages thereof, may best be understood by reference to the following description, taken in connection with the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS FIG. 1 is a view of four electrocardiograms illustrating normal QRS-portions along with different types of supraventricular and ventricular extrasystoles;

FIG. 2 is a diagram of a normal QRS wave form of a basic heartbeat;

FIG. 2a illustrates a rectified QRS wave form of a basic heartbeat along with the temporal correlation of impulse time-windows utilized in the analysis and the obtained threshold impulses of the scanned portion of the wave form;

FIG. 3 is a diagram of the logic system utilized in the apparatus of the present invention;

: rner of'obtaining analysis impulsesyandtl electrocardiogram with differentltypesof extrasjgsttales. The waves indicated bythe numeral lwdepictqthe reg normal QRS-portions of the electrocardicigrarniy The V extrasystoles (SE S)"whichhappear after the i regular two normal QRS-portions 1. The waves indicated by numeral 4 are ventricular eittrasystoles which appear in v thefinal phase of thestimulation; Numeralsiland o i t L m;

I ing apparatus, generally indicated by numei'al ;l0,is it threshold values generate comparator signals which acfrequently (which not only includes variations of the observmlolh toflthe w s @I 1d as lcal with a pre-stored referenceQRSportibn, a su it waves are rectified. Moreoveryin FlG. 2; threshold levelsSl and SH are introduced by means of /oltage l vider. Pulses (also referredto astimewindowsjf P; .1. P are also introduced by tw o counters, desc ibed more ,fully hereinafter. These ipiil sesof time windows are of equal amplitude and duration and occur the en;

analyzed part of the electrocardiogram, i

FIG. 4is a schematic View showing a different nia FIG; 5 is a' block diagram ofithe'tn nitoring lapp a tus, in accordance with the presentinvention.

DESCRIPTION OF THE PREFERRED I and Sll arennduced l l portion flFllGg zah pu se Stpophate more fi described ina fter, while e pulses SQ, slzf an d Sflcoincide with the characteristic tirne winln theyeitainplshowil the pii es i 'thth 'mewinddwstl' and e it EMBQ M I a Referring now to the drawingsl FIG. 1 illustrate a lar heartbeat whicl'lwill jbe :hereinafter described as waves indicated by numeral depict supraventricular QRS-portions 1. Various types of ventricular" extrasystoles (VES) are also shown, The numeral-3indicates ventricular extrasystoleswhich appearin the: middle of dicate various polytope extrasystoles. H

I h l fs p ndingAND gate l n accor ance wit t e present invention, a monitor lmahhqre? the pulse S1 G Hams ihe? P u gat t t t Ll fof the third groupwhichcorrespondstotheparticug s mcluddgs s l l lar tiniewindow frorii thqcdunter Z2.flheiiotmati on ot l O t e 0 Serve Ion O 5 the bit pattern b g-mistypical for the QRS-portion"in into parts of equal latitudes. Means are then provided e c 2a merfr gtbred linithewimertrfiedliatee l for transmitting two or more thresholdlvaluesat the R stoh'lgeFF l e t l t Q W I Fun I W wave of a basic QRS-portron l for comparisioni. These li y q s that g lQfl kp induce a lciifterent bit pat rn ancl the comparison fo f portion is notlrectirded nqn-ide n ticah the individual tolerance of the QRSwpdrtion'of the 3 patient must be considered. T'l'hisgisaccomplish dfjby allovllingthe stor agetcyble; to ru n forQOseoon in this man erga repre sentativj profile cf cheir releva variat' ns the QR terns. e e "portionof the patient under obse rvation isreceived and f Byconsidering the physio'logical fact that the norinal Q RwI ly q l l ST U PW ecg of a patient will not always b e'lregular but will varyu "recogmzed lrrelciv'dmtappear qulmg Subsequent RRintervals, i.e., respiratialarrh'ythmias, but variations j' lQ l y fa m l ll Fg F f in the QRS -portions), the QRS portions of theob them ed 98 5t e qt angem a h t g a served patient are firstrecorded' during a Z O-Second i ws th tramed l j F Q II reference storageflperiod alonglwithcall of the variar; ,l tions. The QRS-portionsof thesubs'equentlly recelved ecgare then shifted into a secondxstorage and then; compared with the preselected ecg oflthe first storage It the observed QRS-portiondoes not coincide with the l v I t e n e QRS-portion of the pre-storedreference ecgga logic f nqel ithti x p w hre ho d l I analysis circuit will indicate a non-identity and a ven q j lf a gq P mPPqH f threshol isis use hthe sensr tricular extrasystole (VES) willbe recognized and regi y t g zationtises along with thentlfitb istered. If, in a preadjustable time distance of a basic f Q ge te e ence registers. in accordancevvitht RR interval, a ORS-portionisrecognizedaarid is -identih a pl hqanalysis ishccomplishedby grotip w hlp gSaysrqup zw i3ul zflyahdygroup" Q3 it praventricular extrasystole (SES) is diagnosed t lw hsp l ysi t6 g r eli i s p y windo FIG. 2 illustratesnormal values of a basic ,QRS I p ses of equal latitude andlamplitude (inthe example, portion with a T-wave. FIG. 2a shows the same signal mp fi- Poy the a n y countertla as that shown in FIG. 2 except that thetQ and theS' operated by pulse szi pt fx a niilcd number (if cides wtth o rieof tlie two tmteswih wsof e GflbytheAND gatesU of groupQg the pulse S ,co- I 1 incides withene oftheftirneywindows P yand e tire duration of the time interval correspondingto the the AND gates U, of group G if the pulse S with one of the pulses P, P

During this -second storing cycle, the store input 22 is triggered by a store pulse and the information of the intermediate storage FF is shifted via an AND gate U H to the main storage FF which-consists of flip-flops. The inputs of the AND gate U are connected to the corresponding flip-flop outputs of the intermediate storage FF and the main storage and the outputs of the AND gates U are connected in groups to the outputs of the OR gates 0,

The outputs of these three OR gates lead to an AND gate U, which is triggered by a control impulse I The main storage FF therefore,'has stored at the end of the 20-second storage cycle in its flip-flops a characteristic bit pattern or compare pattern of the QRS-portion of the observed patient. In the following observation period, in each of the three groups G G G of the compare circuit, in at least two corresponding flip-flops of the intermediate storage FF; and main storage FF are identical, the AND gate U will be set on the binary code log. L, i.e., that the outputs of all three OR gates 0,, are set on log. L." After each analyzed QRS- portion, a control impulse I registers that the condition at the input of the AND gate U J is satisfied so that the output U J is supplied with a positive pulse I which confirms an equality of one of the previously stored QRS- portions and the QRS-portion of the observation cycle. If, in one or more of the three groups, an equality of the corresponding flip-flops in the intermediate storage FF and main storage FF H is not found, at least one OR gate will not be set by a positive pulse on log. L," and at least one input of the AND gate U, stays on log. 0. Therefore, the output is on log. An inverter 23 is inserted between the AND gate U, and the AND gete U and the AND gate U is set during the 1,, pulse. The positive pulse NJ, commanded by the AND gate U will then signalize a ventricular extrasystole VES.

coincides An automatic reset pulser V, will command the intermediate storage FF to be cleared from the information after each recognized and compared QRS-portion between the intermediate storage FF and the main storage FF so that the intermediate storageFF is free for a new QRS-portion detection. The reset pulser V which puts the main storage FF into the standby position, will be induced only in the beginning of a new storage cycle.

The variations of the whole QRS-portions-are recorded in a storage cycle in the main storage FF and at least in groups G and G a number of flip-flops are always set. For the continuous QRS-comparison it is sufficient that in each group at least one flip-flop in the main storage FF H is in coincidence with a corresponding flip-flop in the intermediate storage FF in order to classify a received QRS-portion as normal for the observed patient. If, in one or more groups, an identity does not exist between the corresponding flip-flops in the intermediate storate F F and the main storage FF a ventricular extrasystole will be signalized.

For the examination of polytope VES, additional equipment is provided. A VES store indicated by numeral 20 in FIG. 5 with the same bit capacity as the intermediate storage FF in FIG. 3, .a takeover logic and a compare logic all consisting of AND gates, again similar to that shown in FIG. 3. The takeover logic operated by the pulse N] of the AND gate NJ shifts the last analyzed VES pattern out of the intermediate storage FF Z into the VES storage 20 analogous to the storing in the main storage FF Parallel to the recognition of a new VES in the intermediate storage FF the compare logic also examines in a manner similar to the AND gate U in FIG. 3 the previous VES in the VES store 20 with the new VES in the intermediate storage FF If both VES bit patterns, in the intermediate storage FF and the VES storage 20 are proved as identical, only a VES will be signalized. In case of non-identity, a polytope VES will be signalized. After each VES identification. the previous VES in the VES storage 20 will be eliminated and the last VES commanded from the intermediate storage FF will be put into the VES store so that only the last VES is used as reference for the following VES comparsion.

Ventricular extrasystoles with equal origin of stimulation can exhibit different shapes in the ecg so that even monotope VES could be interpreted falsely as polytope VES. To protect against this faulty analysis, the width of the pulse tolerance is increased by increasing the pulse duration of the pulses S S and 5, about 50 percent of the pulse duration of the time windows P P Thus it is ensured that a pulse appearing in the external zone of two time windows is not only in one but in both windows recognized and, therefore, those two corresponding flip-flops are operated.

This action is described in FIG. 4. In the FIGURE are shown two VES with the same stimulation center (monotope) VES and VES (for simplification, VES is drawn on VES with only small variations in the ecg wave shape. FIG. 4 also shows the corresponding time windows and the pulses S and S induced by VES and VES whereby the pulses are much shorter than the pulses P P P etc. FIG. 4 also shows the same pulses with an enlarged pulse duration of the pulses S and S For simplification the analysis is explained only by passing the threshold S VES induces the pulse which coincides with pulse P VES induces pulse S but appears together (in phase) with pulse P so that two different store flip-flops would be set and the logic would analyze a polytope. If those pulses are used according to the bottom of FIG. 4, pulse S will appear as above in pulse P while pulse S is present in pulse P and P The equal position of operation of the corresponding flip-flops of pulse P in the intermediate storage FF and in the VES store 20 will analyze both VES as monotope as to the threshold pulse 5,. According to the above, the same operation is used for little variations of normal QRS-portions.

FIG. 5 illustrates a block diagram of the monitoring apparatus 10. In the described embodiment, the received ecg of the patient is fed into an input 11 and then amplified by amplifier 12 which includes a low pass filter. A suppressor 13 is provided to suppress the zero-line fluctuation. The amplified signal is rectified and increased in its amplitude up to a standard value in an automatic amplifier 14. From this amplitude, two or more threshold values are derived by a voltage divider 15. In the present embodiment, the two threshold values are provided with their amplitude being 30 percent and percent, respectively, of the medium R'wave amplitude. The linear counters Z and Z (FIG. 3) are part of the analog digital transducer 16. Moreover, two comparators, equipped with differential stages, form part of the A D transducer I6. The groups of AND gates U belong to the takeover logic 18. The AND gates U,, and the OR gates 0 are part of the reference logic 21.

An electronic counter releases an alarm system 27 and 29 as soon as a predetermined frequency of VES or SES is exceeded. The limit rate can be chosen by the doctor. The device is also able to recognize and signal.

consecutive VES or SES not interrupted by abasic the alarm unit 26 provided to signal the existence of polytope VES! For detecting a VES on the T-wave the -known function of the QT-duration and the RR- distance (6T flfifi) from the foregoing R-R- interval is used. The QT-duration is derived from each cycles occur to provide. an observed bit pattern; means for comparing sai d observed bit pattern with said reference bit patterns; and. p it means for energizing an output circuit" in response to any departuresof each observed. bit pattern from said stored bit patterns. i g 2, The combination of claim 1 wherein said means "forestablishinga sequence of time viiindows comprises at leastone linear counter; responsive to the initial induced pulse for generating tachpulses of equal amplitude and durationi 3. The combination of claim 2 wherein said means for identifying the respective time windows in which each induced pulse occurs comprises:

a plurality of AND gates responsive to and said tach pulses; and i a plurality of flip-flop circuits for receiving the outputs of said respective AND gates and delivering a H plurality of output pulses in response thereto.

4. The combination of claim 3;wherein said storage means comprises:

preceding R-R-distance, and hereinduring the interval of the T-wave, a time window operates at about 200 ms. Exclusively during these 200 ms an analysis circuit is activated to indicate gradient and amplitude of a normal (reference) T-wave. If another T-wave differs by a certain value in the gradient and/or amplitude from this reference, a VES on the T-wave (R on T phenomenon) is alarmed. These components areillustrated on the lower portion of FIG. 5, part of which are indicated by numerals 31, 32 and .33. r i

As can be seen, these different accoustical and optical alarm systems shown in FIG. 5 permit the doctor to initiate necessary therapy measures to reinstall the basic heart rhythm of the patient. It should be noted that various modifications can be made to the apparatus while still remaining within the purview of the following claims.

What is claimed is: n 1. Apparatus for monitoring electrocardiograph signals comprising:

means for scanning wave sections of the heartbeat cycles of the ecg signals; means for establishing at least one threshold poten tial level on the ecg signals; means for producing pulses corresponding to the mo ments each scanned wave crosses each threshold level; means for establishing a sequence of time windows occurring during the scanning period; means for electrically identifying the respective time windows in which each induced pulse occurs over several normal heartbeat cycles to provide reference bit patterns; means for storing said normal bit patterns; means for electrically recording the time windows in which induced pulses from subsequent heartbeat a second plurality of AND gates responsive to the output pulses of said flip-flop circuits; and a second plurality of storage flip-flop circuits for receiving the outputs of said second plurality of AND gates andfor delivering a plurality of output pulses in response thereto. i 5. The combination of claim 4 wherein said comparing meanscomprises a third pluralityof AND gates responsive to the output pulses of said firstand second plurality of flip-flop circuits. 7

6. The combination of claim 5 wherein said means for energizing an output circuit comprises:

a plurality of OR gates responsive to the output of said third plurality of AND gates;

a fourth AND gate responsive to the outputs of said means for producing an output command responsiv to said fourth AND gate.

7'. The combination. ofclaim 1 wherein saidmeans for establishing at least one threshold potential comprises an analog-digital transducer.

8. The combination of claim 1 further comprising:

means for storing the observed bit pattern that is a recognized non-identity with the reference bit pattern; and

means for comparing the bit pattern of the stored,

observed bit pattern with a bit pattern of the following non-identity observed bit pattern to identify the non-identity of these bit patterns as a polytope ventricular extrasystole.

9. The combination of claim 7 further including means on said analog-digital-transducer for enlarging the duration of said induced pulses to enable the pulses to be received in the adjoining time windows so that natural variations of normal wave sections will not be interpreted faultily.

induced pulses. 

1. Apparatus for monitoring electrocardiograph signals comprising: means for scanning wave sections of the heartbeat cycles of the ecg signals; means for establishing at least one threshold potential level on the ecg signals; means for producing pulses corresponding to the moments each scanned wave crosses each threshold level; means for establishing a sequence of time windows occurring during the scanning period; means for electrically identifying the respective time windows in which each induced pulse occurs over several normal heartbeat cycles to provide reference bit patterns; means for storing said normal bit patterns; means for electrically recording the time windows in which induced pulses from subsequent heartbeat cycles occur to provide an observed bit pattern; means for comparing said observed bit pattern with said reference bit patterns; and means for energizing an output circuit in response to any departures of each observed bit pattern from said stored bit patterns.
 2. The combination of claim 1 wherein said means for establishing a sequence of time windows comprises at least one linear counter responsive to the initial induced pulse for generating tach pulses of equal amplitude and duration.
 3. The combination of claim 2 wherein said means for identifying the respective time windows in which each induced pulse occurs comprises: a plurality of AND gates responsive to induced pulses and said tach pulses; and a plurality of flip-flop circuits for receiving the outputs of said respective AND gates and delivering a plurality of output pulses in response thereto.
 4. The combination of claim 3 wherein said storage means comprises: a second plurality of AND gates responsive to the output pulses of said flip-flop circuits; and a second plurality of storage flip-flop circuits for receiving the outputs of said second plurality of AND gates and for delivering a plurality of output pulses in response thereto.
 5. The combination of claim 4 wherein said comparing means comprises a third plurality of AND gates responsive to the output pulses of said first and second plurality of flip-flop circuits.
 6. The combination of claim 5 wherein said means for energizing an output circuit comprises: a plurality of OR gates responsive to the output of said third plurality of AND gates; a fourth AND gate responsive to the outputs of said OR gates; and means for producing an output command responsive to said fourth AND gate.
 7. The combination of claim 1 wherein said means for establishing at least one threshold potential comprises an analog-digital transducer.
 8. The combination of claim 1 further comprising: means for storing the observed bit pattern that is a recognized non-identity with the reference bit pattern; and means for comparing the bit pattern of the stored, observed bit pattern with a bit pattern of the following non-identity observed bit pattern to identify the non-identity of these bit patterns as a polytope ventricular extrasystole.
 9. The combination of claim 7 further including means on said analog-digital-transducer for enlarging the duration of said induced pulses to enable the pulses to be received in the adjoining time windows so that natural variations of normal wave sections will not be interpreted faultily. 